Access governs prostate cancer survival

ACCESS to a quality network of GPs, specialists and treatment options close to home remains the key to closing the gap in prostate cancer survival rates between rural and urban men, say experts.

Research published in the MJA has highlighted the urban–rural difference in prostate cancer survival remains despite increasing awareness. (1)

Using data from 68 896 men diagnosed with prostate cancer in NSW between 1982 and 2007, the researchers found that although overall 10-year survival increased from 57.5% in 1992–1996 to 83.7% in 2002–2007, men diagnosed with prostate cancer who lived outside major cities had a higher risk of death from prostate cancer (relative excess risk, 1.18 for inner regional and 1.32 for rural areas).

The authors tried to account for urban–rural variation in prostate cancer incidence rates caused by differences in the intensity of prostate-specific antigen (PSA) screening and socioeconomic disadvantage. Other variables included were age at diagnosis and spread of disease at diagnosis.

Professor Mark Frydenberg, chair of the department of urology at Monash Medical Centre, Melbourne, said the research was a “good snapshot”.

“The [urban–rural differential] can’t be blamed on one single thing”, Professor Frydenberg told MJAInSight. “It’s a constellation of factors at work.

“You’re dealing with a population of tough farmers … They don’t go to the doctor unless they have a very good reason.

“Demographics, a lack of access to GPs, decreased PSA testing and poor access to specialists — all are factors.”

Professor Frydenberg said the solution was to improve access to rural GPs and, particularly, specialists in rural areas.

“There is US research that shows that the best way to [improve survival rates] is the presence of a local urologist”, he said. “It’s pointless screening if there is no service to follow up on the screening results.” (2)

The overdiagnosis of non-significant cancers via PSA testing was cited by the MJA authors as a possible confounding factor in inflating the survival rates of urban patients.

Regardless of the controversy surrounding PSA testing, Professor Frydenberg said it was “better than nothing”.

Professor Ian Haines, oncologist at Cabrini Private in Melbourne, was critical of the research because it did not present age-adjusted mortality figures to suggest that men were dying younger from advanced prostate cancer in rural areas.

“The large increase in diagnosis and ‘survival’ for prostate cancer, particularly in urban areas, is due to greater use of the PSA, which is a very unreliable screening test”, Professor Haines told MJA InSight.

“This paper again highlights the importance of establishing accurate and sophisticated prospective databases in Australia … and then this issue could be resolved and perhaps vast savings made, and lives improved, by reducing our overdiagnosis and overtreatment of early stage prostate cancer”, he said.

Professor Richard Murray, president of the Australian College of Rural and Remote Medicine and dean of medicine at James Cook University, said that the study underscored the importance of rural communities having access to high quality health care as close to home as possible.

Professor Murray told MJA InSight that the best approach was a “system of care” arranged around the patient and their family.

"In rural areas, this means a network of skilled rural doctors, working as part of their local primary care and hospital teams and with their remote consultant colleagues, including oncologists and surgeons”, Professor Murray said.

“However diagnosed, it is critical that rural men with prostate cancer have local access to trusted advice and support to make the best decisions about their care”, Professor Murray said.

Dr Ian Kamerman, president of the Rural Doctors’ Association, said rural men had suffered worse outcomes than urban men prior to 2007 for the simple reason that radiotherapy units had not been available in rural areas before that date.

“Radiotherapy is a major component of treatment for prostate cancer”, he told MJA InSight. “I agree there was a difference between outcomes for rural and urban prostate cancer patients. Whether there is currently a difference I am less sure about.”

Management strategies for erectile function rehabilitation for survivors of prostate cancer survivorship was the focus of a clinical report published in the MJA. (3)

“Patients should be presented with all treatment options, and told that rehabilitation and treatment for erectile dysfunction as early as possible after prostate cancer therapy will result in faster and better recovery of erectile function and preserve sexual continuity”, the authors wrote.